Provider Demographics
NPI:1942373766
Name:WEIMER, MICKEY RAY (CFA)
Entity Type:Individual
Prefix:MR
First Name:MICKEY
Middle Name:RAY
Last Name:WEIMER
Suffix:
Gender:M
Credentials:CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1963 W LONESOME DOVE ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-8271
Mailing Address - Country:US
Mailing Address - Phone:208-724-6139
Mailing Address - Fax:
Practice Address - Street 1:323 E. RIVERSIDE DR #234
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-938-4080
Practice Address - Fax:208-938-8922
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID97391246ZS0410X
97391246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist